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Who is an Eligible Provider? An Easy Penalty to Avoid

  Sep 14th, 2015   -     News   -  

Do you know without a doubt exactly who all of your PQRS Eligible Providers (EPs) are? Would you be willing to bet $18,000 per provider on it? For a practice of five physician and five non-physician EPs (PAs, NPs, PTs, RDs, etc.) an innocent misunderstanding could mean a $180,000 stroke against the entire practice. Many practices will be surprised to receive the maximum penalties (-4% to -6% of all Medicare billings) in 2017 because they failed to report data from enough providers in 2015 due to accidentally leaving one or more out. Here’s what you need to know to avoid that scenario. Contents
  • Who is an Eligible Provider
  • Individual vs. Group Reporting
  • Avoid This Group Reporting Penalty
  • A Simple, Error-Free Filing System
Medicare defines PQRS covered services as those paid under or based on the Medicare Physician Fee Schedule (MPFS). If an EP (see the list below) provides services that are paid under or based on the MPFS, those services are eligible for PQRS payment adjustments. Who is an Eligible Provider (EP) for PQRS?
  1. Medicare Physicians – Doctors of Medicine (MD), Osteopathy (DO), Podiatric Medicine (DPM), Optometry, Oral Surgery, Dental Medicine (DDM), and Chiropractic
  2. Practitioners – Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist (including Advanced Practice Registered Nurse (APRN)), Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant), Certified Nurse Midwife, Clinical Social Worker, Clinical Psychologist, Registered Dietician, Nutrition Professional, Audiologist.
  3. Therapists – Physical Therapist, Occupational Therapist, Qualified Speech-Language Therapist
It is imperative to include all of a practice’s eligible providers when calculating total number of Eligible Providers for filing. Failing to do so could cause the practice to receive the maximum negative penalty even though their PQRS data was filed correctly. Individual vs. Group Reporting The next step is to determine whether the practice will be reporting PQRS measures under Individual or Group (GPRO) status. A group practice of 2 or more EPs whose providers have reassigned their billing rights under the practice’s TIN may file as a group under the GPRO classification. The deadline for applying for GPRO was June 30, 2015. If a group selected filing GPRO, then all EPs’ PQRS quality measures must be filed. Solo practitioners  and practices that did not meet the June 30th GPRO filing deadline and must file their PQRS measures as Individuals. Practices of 2 or more EPs must file measures for at least 50% of their providers. How to Easily Avoid This Group Reporting Penalty By not accurately counting all of a practice’s eligible providers (perhaps by accidentally leaving out some provider types) it is possible to report for fewer than 50% of EPs, and therefore receive Medicare’s automatic maximum -4% or -6% penalty, which is applied to all Eligible Providers in the practice. A Simple, Error-Free Reporting System By using a Data Submission Vendor (DSV) like Health eFilings, a practice eliminates the possibility of being penalized for not filing measures for enough EPs. A DSV is able to extract all of a practice’s EP data from their EHR, and then aggregate, format, and send it to Medicare. This process is the same for both Individual and GPRO filers, and Health eFilings handle the entire process so that no clinic staff time or IT resources are required. Next week we will compare the different ways to file PQRS data and identify which is the most cost-effective method for your practice. Learn More About PQRS Reporting at Health eFilings